This was a comprehensible discussion of the issue of mandates in coverage. However, three points: 1) “At the same time, I can also respect, while disagreeing with, Candidate Obama’s decision to exclude a mandate.” I think this means that at some point mandates will be essential to make coverage universal, and not simply because this will make it universal because everyone will be “commanded” to participate, but rather that it will be necessary to keep the costs manageable. I do have concerns, when I read who Obama’s economic advisers are, that he doesn’t get this…BUT, I also would like to point out that mandates vs. no mandates is not really an issue of extremes on a spectrum, unless you are thinking of a very tiny spectrum. At some point, should Obama be president, one can see a change to mandated coverage, OR even better, a different mechanism altogether. I would really like to see someone come up with something laypeople like me could understand which would show:
1) parallels in cost and coverage between universal single payer coverage and this plan that includes existing insurance coverage. These parallels could include administrative costs, the costs of for-profit vs. not-for-profit plans, costs of changeover from the present system for both approaches, costs for individuals, etc.
2) what the consequences of overtly shifting to a single payer plan would be in terms of the national economy.
3) why people are afraid of coming out in favor of moving to a single payer plan.
4) if mandated coverage under a Clinton plan is something that favors more or less the status quo or the profit status of companies more than it favors anyone else or not.
5) if there are any other alternative plans that work with a private-public mix.

I know this sounds like it requires someone to write a book few people would read, but I think unless there is a way to actually explain things to non-economist voters, there is going to pandering….mandates do sound scary to people who are already struggling financially so a candidate might choose to avoid saying they are necessary. And I do believe in spite of Gruber’s assertions that everyone gets affordable coverage in Massachusetts, there have been problems there. And once again I will say that I wish Obama would get better, or let’s say more people-oriented, less man-as-rational-decision-maker, advisers.

If US Heath Care is a factory, the widget it delivers cost more, is a defective product (as measured by health outcomes), and its distribution system a fails to reach a significant portion of the population…

A reasonable manager, faced with a failing factory, would study a successful factories. In this case, European systems with better widget outcomes and a distribution system that reaches all the population.

Now then, the European widget factories differ, one from the other, but they have one thing in common: At the base of the widget, single pay, government sponsored programs.

Three such models exist in the US: Medicaid, Medicare, and the VA system. Pick, blend and go to it.

I have this problem, when part of my health care dollar goes to support the insurance companies (1 to 40 million dollar executives) can I call that taxation without representation?

Mandated purchase of private health insurance could cost near 45% more than Medicare for all:
Private insurance is supposed to add 30% costs (20% insurance provider paperwork and procedure denial machinery and 10% doctors dealing with multiple plans paperwork and fending of denial). 30 is 42.8% of 70: near 45%.

The poverty line multiples really need to be cut in half (adjusted for reality if you will) before discussion of income levels even begins — because the federal poverty line is based on the useless (if too obviously understated) measure of three times (3X) the price of the cheapest possible emergency diet (dried beans only, no canned beans allowed!). The 2002 book Raise the Floor has a professionally worked out poverty line which comes to twice (2X) the official federal line.

Whatever multiples of poverty a person’s wages may be, some individuals will not be in a position to purchase insurance because of their personal situations, making for potential tragic situations in a programs supposedly trying to help. We equally need to take into account the tragic state of wages on the low end in this country thanks to the race to the bottom that began in the early 70s. Our standards for what people should be paid are way off what they would be in an adequately unionized country, for instance — potentially leading to more misjudgment on the impact of mandates that people really cannot afford.

The only reason I ever see progressives state for not advocating Medicare for all as the best alternative is their assumption that politicians will be too overwhelmed by the politicking of the insurance companies — no other objection. Seems a weak rationale to throw their support behind a basically undesirable program right at the beginning of national discussion. Especially when polls show Americans to support Medicare for all as the ideal way to go. Show a little moxie fellows and maybe one of the politicians will get their courage up and follow you (Huckabee?) — couldn’t happen?

The Democratic candidates health care proposals all are doomed to the same failure any system that perpetuates the “for profit” American health care system, As long as there is profit from sickness, people will become sicker because greed necessitates it.

Only when wellness is the goal and sickness becomes unprofitable will there be a system that will work for the American people.

You realize that Gruber is not an unbiased observer. Michael Dobbs (Washington Post Fact Checker) used Gruber to defend Clinton’s health care policy in November. You know, because his is Clinton’s Health Care Advisor.

Seems to me this is begging the issue. Gruber, expert as he no doubt is, doesn’t deal with the fact that any universal health coverage plan relying on insurance for coverage is only a short term proposition at best. How are costs controlled? Exhibit A is Medicare Part D, the prescription drug plan. All provided by insurance. Costs have already escalated rapidly even in the first two years of operation and will increase again next year with no end in sight. In short order we would have to do major surgery on universal insurance plans, as is bound to happen with Part D. Single payer under Medicare is the next step but Medicare cannot control those costs very well either. Why not start with the only way to control costs in the long run, that being the model of VAHS? Of course you cannot establish that on a universal basis for starters but you can extend the model to cover all veterans and their families.
–JD MacFarlane

Missing in most all these arguments, especially those pointing out the unfairness of mandated health insurance, is that all those without insurance really have insurance. If they get sick or have a medical catastrophy the rest of us end up paying for it, albeit after they have lost their homes and other assets.

Get real folks, Professor Krugman has pointed this out as have many others.

An ugly aspect of mandates enforced via heavy fines — as I believe is the case in Massachusetts — is they too much resemble the action of illegal drug penalties: the state harming you badly if it catches you doing something that could potentially harm yourself.

Comparing health insurance mandates to auto accident insurance mandates wont do. You have a choice not to buy a car you cannot be responsible for. You are permanently trapped in the state of being a human being, ability to be responsible for your health coverage or no.

See my comment above about being too casual assuming that varying ability to be responsible can be linked mechanically to a scale of income levels.

Well, I keep reading more on this topic and remain unconvinced of the necessity of mandates in the initial step toward achieving a unversal, single-payer system. The claim here seems mainly that ‘most experts like mandates.’

There’s an excellent post on the Ezra Klein site to which Dr. Krugman links above. (Posted by: John Rawls | Dec 6, 2007 6:54:46 AM) This post makes a lot of sense to me in that it acknowledges the re-insurance component of Obama’s plan as well as the perspective that the current campaign proposals are a means to an end (hopefully a universal, single-payer end).

Do you realize that mandating health insurance is still, in effect, feeding a corrupt system. Did you read about the “give back” of $418 million by McGuire, the guy who built United HealthCare? That money came from inflated premiums and deflated payments to physicians, etc.

There is one explanation for Obama’s Social Security and health care positions; generational politics. Potential young voters believe that Social Security will not be there for them and they resent the fact that the deductions they see in their meager paychecks will fund feckless Boomer 30-year retirements. And why should they buy health insurance when again their payments just fund the health care of old drug-addled hippies. I work with college students and know that these sentiments are not unusual.

I want to believe that Obama’s soaring rhetoric is appealing to something more than that. Then he adds the stuff about not going back to the tired old politics of the 90s or the generational wars of the 60s. I am a Boomer and I have to admit that he does have a point, we are largely responsible for Clinton and Bush. I want this nightmare to be over too.

I am also an Iowa Democrat and a month ago I was undecided but confidant that this field would produce a Democratic President who, along with a Democratic Congress, could begin to repair the damage that Republicans have done here and abroad. Now I am not sure I want to replace the generational wars of the 60s with the generational wars of the new millenium. After the students go home for break I am hoping that Obama and Oprah will convince me that he is bigger than that. If not at least Edwards and Dodd have defined the issue in a way that we all can support; checking corporate power and restoring the proper role of government.

Prof. Krugman, since you like mandates so much, let me ask you a question – what happens when I cannot afford the mandated coverage but I am not anywhere near the poverty line? In fact, I am largely self-employed as a consultant and make a decent (not great) living, yet none of the healthcare reform proposals seem to address my peculiar situation: the need for affordable medical insurance outside of the employer-provided system. I can tell you how much I’ve had to pay for my own coverage, or COBRA coverage and they are prohibitively expensive. How can I be sure that the coverage I am forced to purchase will be any less expensive than it is now? To my mind, “universal” healthcare means that everyone has coverage BY DEFINITION. Automatically.

A universal health care system is another engineered system of comprising mainly of human beings. Much like our founding fathers tried to engineer our political system, trying to put in checks and balances, accountability, so that it would run fairly well even with flawed human beings with a diversity of self-interest, should not the same thought and care go into this infrastructural project?

In today’s world, I see doctors legally but unethically scamming insurance companies with passive acquiescence/ignorance of the patients, and one would have thought that private insurance companies have a much stronger self-interest in containing this than any governmental entity.

As a concrete example order a unnecessary test, and spend thirty seconds “reading” the test results. The insurance co pays fifty dollars for that 30 seconds. It is risk-free for the doctor to spend only 30 seconds because she/he knows that the test was not intended to reveal anything. The only possible check I can see on this is by the patients, and for that, the (unnecessary) tests that the doctors order must impose a cost on the patient.

I think how to pay for universal healthcare is actually the lesser problem. There is a greater problem here – how to institute accountability into any system of universal health care which will have participants with widely different ethics and yet not to deny people required treatment. I think if we can solve the greater problem, the lesser one will take care of itself.

Simply for breathing the rarified air of our nation, to impose a fiat that everyone suddenly purchase private health insurance plans off the commercial product shelf–in many cases with government help by subsidizing those same private plan payments–requires some hubris.

Auto insurance is a reasonable condition accompanying what is a totally discretionary commercial expense of buying wheels. An optional product, really a luxury for most.

The only way a mandate would be honest in implementation is if you excluded the commercial interest. And here’s Krugman (of all people) arguing he effectively has no problem with requiring everybody to suddenly tax themselves to the moon but with the unique twist that this sudden, dramatic tax increase benefits not a non-profit care pool (single payer), but a profit driven collection of corporations. (The conscience of a liberal?)

At 12% per year added on top. Still no mention of the details of cost control. Where does government end and commercial interests begin anymore?

Thanks you for today’s (December 7) column. It lays out beautifully the differences between the Obama plan and the Edwards/Clinton plans. AND points out the real dangers with Obama’s approach. As I have said before, I really worry about Obama’s advisers. I sure hope he is paying attention to you!!!

I utterly agree with David B Brooks (hopefully not THE David Brooks!?)- reimbursement needs to incentivize improvement and wellness- as it stands now, if a kidney patient declines and goes on dialysis, the hospital gets alot more $ than if the patient stabilizes without further intervention- disincentives are starting to be adopted here, viz. denial of reimbursement for nosocomial infections, but we need a broad policy change to incentivize wt. loss, blood pressure control, sugar control, etc. in order to minimize hospital visits thereby minimizing the ensuing gigantic costs

Bravo, Paul Krugman, for your justification of health insurance mandates in today’s (12/7/07) column. We’re all in it together with respect to health care, whether or not we know it, because it is simply too expensive for anyone except the very wealthiest people. I suggest you might write a series of column teaching health care and insurance economics.

how long can you keep up the tirade about Obama using “right wing talking points” (Atrios makes the same arguments against mandates as Obama – is he “right wing, Mr. Krugman?) without mentioning that Hillary – your obviously preferred candidate, does the same thing but far more often, and far more egregiously? please don’t play into the trap your critics have set for you. don’t be so openly and obviously biased.

When Mr. Krugman said mandates do work in Switzerland and the Netherlands, he very conveniently excluded that income taxes in those countries are almost 70 percent. Does this mean Senators Clinton and Edwards want to raise taxes by that much or Mr. Krugman is on his own?

Although Mr. Krugman is a smart man, his way is not the only way to skin a cat.

If Mr. Krugman had to buy his healthcare out of pocket, facing the realities of millions of uninsured or more precisely “under” insured, he might hold a different opinion about the proposals. If Mr. Krugman had a low-wage job and was already struggling to keep up in this economy, he might feel a little differently about healthcare mandates. And if Mr. Krugman — as an uninsured citizen — had ever spent hours in an emergency room waiting for what the rest of us consider routine care for a sick child, he might be advocating a different policy.

The problems with American healthcare are less about who has insurance but about the access to healthcare. Those on the fringes do without and hope they don’t have the accident or illness that requires expensive care. Those with insurance are tethered to their employers and face cost increases, limits to coverage based on usage and pre-existing conditions. The self-employed have a tough task of finding affordable insurance with reasonable coverage.

While Mr. Krugman argues about mandates, some of us just need access to care. If Mr. Obama’s plan brings 32 million of the 47 million uninsured — uncovered — into the system without mandates, I can live with that. Experts other than Mr. Krugman say both Clinton and John Edwards will end up with about 15 million who are also uninsured. It’s a wash.

Krugman keeps beating this drum because he either is planning to endorse Hillary, someone else or — more intriguing — he secretly supports Obama and is just trying to throw us off his trail.

Healthcare is not the only issue on which I will base my vote. And healthcare as Senator Obama has proposed it — or as any presidential candidate proposes it — will not be the final version implemented in his administration. Heck, we might end up with Kucinich’s plan in an Obama presidency.

But I can and do support Obama’s ideas as the best ways and means to achieve solutions to the crippling issues of our generations.

BUT I would still like to understand more about the place of insurance companies in all this. Will Obama – Clinton – Edwards plans leave in place the profit-making needs, the incentives to not provide coverage, the bureaucratic entanglements, and the working-at-cross-purposes-so that doctors have to hire extra people to sort out all the different forms, etc. etc.

Could you discuss why none of the candidates feel free to at least talk about single-payer as a final step in insuring Americans? Why they don’t feel they can/should/want to talk about expanding VA benefits, Medicare, and the poor child of the bunch, Medicaid to start incorporating the uninsured and then working from there to absorb the rest of us?

What would be the effect on the economy of chipping away at the insurance companies themselves?

My dad was a physician. He retired in the early eighties. I remember as a child driving by a for-profit hospital which my mother in her characteristically direct fashion described as a place for rich women who were drunks. My father was dismissive, to say the least, scornful, of the notion of profit being the driving force in providing medical care.

Esther B. and others, don’t be lulled into thinking that the mandate approach is beneficent to all b/c it most certainly is not. Mr Krugman’s 12/7 Op-Ed states that Switzerland and the Netherlands are countries that have “successful” mandates but he does not explain that each of those countries has MUCH LESS of a for-profit insurance industry presence. Mr. Krugman also omits the fact that these two countries each have some of the highest per capita health care spending in the world (after the U.S.).

So why in heavens name is a mandate to purchase insurance in the private marketplace the health policy “reform” we should be aiming for? Can’t we do better, much better, supposing we get a Democratic President and Democratic-controlled Congress in ’08?

America needs a leader with a health plan that moves us away from the wasteful and harmful clutches of the private insurance industry, not a plan moves us in the opposite direction! (Which is what a private insurance mandate will do.)

Real folks in MA tell it like it really is with mandates:

Debbie is a friend of mine who’s a free-lance graphic artist of moderate income who wants and needs insurance. She makes under 300% FPL but cannot afford the lowest-priced insurance product that has a subsidized premium and co-pays under the new MA mandate law. Her State Rep’s office has suggested that she become eligible for a mandate waiver by defaulting on her mortgage!!!

Another friend’s income is just over the cut off for state subsidized premiums and b/c she is 57yo the lowest cost insurance product carries a premium of over $500 a month which she cannot afford. Her state Senator’s office staff told her: Too bad, it’s the law and that she should try to get a job a Starbucks b/c they provide insurance and she’d also get a free bag of coffee regularly. Unbelievable but true.

Experts, schmecksperts.
I have not studied Hillary’s mandated health plan, but, as a resident of Massachusetts, I can tell you the devil is in the details. Everyone should pay attention to them. I was paying $10,000 for health insurance, working 18-40 hours a week variably. The job barely covered the insurance and I could no longer afford to pay for it at the end of last year. When the new health insurance plan was implemented, I was delighted – right up until my employer finally offered a policy from a slew submitted by private insurance companies approved by the new state plan.

The catch: the state will assist with high premiums under the new plan, but they do not give a rat’s hind end about co-pays and deductibles. As one representative from the state told me, “The co-pay could be a million dollars and you would still have to pay it: the policy would still be approved.”

My employer came up with a reasonable $200 a month premium policy; lower if you rejected prescription coverage. However, it required payment of a $500 deductible to set foot in a doctor’s office. Prescription premiums were as high as fifty dollars. Given that my company’s employees were earning about $10 an hour, depending on the number of hours of work they could get a each month, there were a substantial number for whom the insurance was useless. First of all, in a random month, the premium could exceed income; and even if it didn’t, they were forced participate in an insurance plan where they still could not see a doctor, because they could not afford the $500 deductible required before a doctor’s visit. Nor could they afford the prescription co-pay.

I don’t call this a plan. I call it piling on the poor. While intentions were good and in many cases successful, there are a number of Massachusetts residents who still can not afford health insurance. The state has some kinks to work out. I’d go for the Obama plan just to be safe.

Comment #13 from Michael Cohen gets it right. I live in MA where there are hundreds of thousands of us who work hard, contribute our part to society, and are left without health care only to find that this new mandate law is making our situation worse.

The state group called MassCare.org (that advocates for universal healthcare using single payer financing reform) has done an analysis of where things stand with the MA mandate law known as Chapter 58. The findings are telling:

– Of the people who will receive no premium subsidies because they make over 300% Federal Poverty level (~$30k for an individual), only 3% have purchased insurance as required under the mandate. I am in this group and I’ll tell you that you can’t get blood from a stone which is what this law tries to do.

– Thus far, of those people qualifying to receive a partial subsidy of their health care premiums, only 12% have signed up. I have friends in this group and the premium share plus the co-pays they are required to pay make the insurance unaffordable if they still must pay their mortgage, heating bills, feed their kids, etc…

– However, for those people who qualify for “free” health care (private HMO coverage that is fully state subsidized, a wasteful way to expand publicly fuded coverage), only about 30,000 people statewide have not registered and well over 200,000 have. This is a much higher figure than was projected and than was budgeted for.

Mandates that force people to purchase private insurance are the wrong way to go to get to universal healthcare. I am extremely grateful that Obama understands this fact.